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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r I APPLICATION ' <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTA?E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) 0 ,M. Address 2 C� %7-, - � ' <br /> i z Owner <br /> [� Address <br /> d i <br /> 1 Firm Partners, Addresses and Tele one Numbers <br /> 4 Business Telephone No. c' Emergency Telephone No. <br /> Contractor Licence No. 717 q <br /> LApplicants Name (Print) Title Date <br /> Please check ApplicableCategory (1-7)and Fill in the Required Information flugnes Const <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) State S. Oro <br /> Ave.7 <br /> 263 S. Oro Ave. <br /> For July 1, -June 30. 11, Disposal Sites Stockton, N 95 05 <br /> Description.(Make/Yr., Color) J <br /> Serial No. CAL. License No. <br /> t Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19- <br /> No. of Vehicles Stored t <br /> s <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST VhI <br /> R.S. or R.C.E. Name �_6 R.S. or R.C.E. No. <br /> Test Location ' ;I� Test Date/Time <br /> 4. tvSANITATION PERMIT <br /> I Job Address/Location i <br /> IAddress <br /> Owner �, <br /> SEPTIC TANK <br /> 1:1 POOL LEACHING FIELD SEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT 11 TEMPORARY KNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 { + <br /> Type Construction - I`: Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT rPLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity `'} No. Units Served <br /> k 7. ❑ LAUNDRY 'For July 1, iJune 30, 19 <br /> I�, <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,.Chemicals.USed/Amounvmo. <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an les an regulations of the San Joaquin L cal Health District. Hughes Const. kC <br /> APPLICANT'S SIGNAL URE X State LIC. #267177 <br /> �r 263 S. Ora Ave. <br /> I Stockton, CA 95206 <br /> fl FOR DEPARTMENT USE=ONLY <br /> N. <br /> I ❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: E3 ANNUALLY! ❑ PER UNIT f ` <br /> REMIT <br /> I BA5E EXPLANATION BILLING REMITTANCE • $ AMOUNT�DUE CHECKED <br /> + * DATE DATE, REMITTED AMOUNT <br /> FEE �� CIL/- <br /> LESS <br /> PRORATION <br /> PLUS <br /> ^� C <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Perit o. `_Issuance Mailed Delivered <br /> m <br /> APPLICANT--RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1601 E HAZELT E.,P.D.Bax 2009 - STOCKTON,CA 95201 <br /> SII —� <br />